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Management of Substance Abuse

Management of Substance Abuse

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Published by: msubu on Nov 21, 2009
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Management of substance abuse
The Management of Substance Abuse Team (MSB) is one of three teams under the workingumbrella of the Department of Mental Health and Substance Abuse and the cluster of  Noncommunicable Diseases and Mental Health. The Management of Substance Abuse Team isconcerned with the management of problems related to the use of all psychoactive substances. Itemphasizes the development, testing and evaluation of cost-effective interventions for substanceuse disorders as well as the generation, compilation and dissemination of scientific informationon substance use and dependence, their health and social consequences. It supports countries inadvocacy and capacity building for the prevention and management of substance use disorders inall vulnerable groups . It seeks an integrated approach to all substance use problems within thehealth care system, in particular primary care.Chapter 2—Brief Interventions in Substance Abuse TreatmentBrief interventions for substance abuse problems have been used for many years by alcohol anddrug counselors, social workers, psychologists, physicians, and nurses, and by social serviceagencies, hospital emergency departments, court-ordered educational groups, and vocationalrehabilitation programs. Primary care providers find many brief intervention techniques effectivein addressing the substance abuse issues of clients who are unable or unwilling to accessspecialty care. Examples of brief interventions include asking clients to try nonuse to see if theycan stop on their own, encouraging interventions directed toward attending a self-help group(e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]), and engaging in brief,structured, time-limited efforts to help pregnant clients stop using.Brief interventions are research-proven procedures for working with individuals with at-risk useand less severe abuse behaviors and can be successful when transported into specialist treatmentsettings and performed by alcohol and drug counselors. As presented in the literature, brief interventions to change substance abuse behaviors can involve a variety of approaches, rangingfrom unstructured counseling and feedback to formal structured therapy (Chick et al., 1985;  Fleming et al., 1997;Kristenson et al., 1983;Persson and Magnusson, 1989). Brief interventions, as defined and discussed in this TIP are time limited, structured, and directed toward a specificgoal. They follow a specific plan (and in some cases a workbook) and have timelines for theadoption of specific behaviors.Several studies have attempted to identify factors that result in differential responses to brief intervention by varying client characteristics or by conducting subgroup analyses. Most studiesof brief interventions to date are limited by their lack of sufficient subject assessments. Findingsfrom the available research suggest that client characteristics are not good predictors of a person's response to a brief intervention and that brief interventions may be applicable toindividuals from a wide range of cultures and backgrounds (Babor, 1994;Babor and Grant,  1991
This chapter provides theoretical and practical information on brief interventions, both inopportunistic settings and in the substance abuse treatment setting. The stages-of-change modelis presented first because of its usefulness in understanding the process of behavioral change. Next, the goals of brief intervention are described and applied to various levels of substance use.FRAMES elements critical to brief intervention are detailed, and five essential steps are listedwith scripts to use in various settings. The brief intervention workbook, a practical tool for useduring a brief intervention, is explained. Essential clinician knowledge and skills for conductinga successful brief intervention are then described. Discussions of the use of brief intervention insubstance abuse programs and nonspecialized settings follow. The final section presents researchfindings on brief interventions for both at-risk users and dependent users.Stages-of-Change ModelThe work of Prochaska and DiClemente and their "stages-of-change" model help clinicians tailor  brief interventions to clients' needs (Prochaska and DiClemente, 1984,1986
). Prochaska andDiClemente examined several theories concerning how change occurs and applied their findingsto substance abuse behavior modification. They devised a model consisting of five stages of change that seemed to best represent the process people go through when thinking about, beginning, and trying to maintain new behavior (see Figure 2-1). The stages-of-change model isexplained more fully in TIP 35,
 Enhancing Motivation for Change in Substance AbuseTreatment 
).These stages have proven useful, for example, in predicting those most likely to quit smokingand in targeting specific kinds of interventions to smokers in different stages (DiClemente et al.,1991;Prochaska , 1999;Prochaska and DiClemente , 1986;Velicer et al., 1992
). Stages of changeare being examined in brief interventions with hazardous and harmful substance users as well, asa means of tailoring interventions to the individual's current stage of change (Hodgson andRollnick, 1992;Mudd et al., 1995).Clients need motivational support appropriate to their stage of change. If the clinician does notuse strategies appropriate to the stage the client is in, treatment resistance or noncompliancecould result. To consider change, clients at the precontemplation stage must have their awarenessraised. To resolve their ambivalence, clients in the contemplation stage must be helped to choose positive change over their current circumstances. Clients in the preparation stage need help inidentifying potential change strategies and choosing the most appropriate ones. Clients in theaction stage need help to carry out and comply with the change strategies.The clinician can use brief interventions to motivate particular behavioral changes at each stageof this process. For example, in the contemplation stage, a brief intervention could help the clientweigh the costs and benefits of change. In the preparation stage, a similar brief interventioncould address the costs and benefits of various change strategies (e.g., self-change, brief treatment, intensive treatment, self-help group attendance). In the action stage, brief interventions can help maintain motivation to continue on the course of change by reinforcing personal decisions made at earlier stages.Understanding these stages helps the clinician to be patient, to accept the client's current position,to avoid "getting too far ahead" of the client and thereby provoking resistance, and, mostimportant, to apply the correct counseling strategy for each stage of readiness. Effective brief interventionists quickly assess the client's stage of readiness, plan a corresponding strategy toassist her in progressing to the next stage, and implement that strategy without succumbing todistraction. Indeed, clinician distraction can be a greater obstacle to change in brief intervention
than time limitations. Regardless of the stage of readiness, brief interventions can help initiatechange, continue it, accelerate it, and prevent the client from regressing to previous behaviors.Goals of Brief InterventionThe basic goal for a client in any substance abuse treatment setting is to reduce the risk of harmfrom continued use of substances. The greatest degree of harm reduction would obviously resultfrom abstinence, however, the specific goal for each individual client is determined by hisconsumption pattern, the consequences of his use, and the setting in which the brief interventionis delivered. Focusing on intermediate goals allows for more immediate successes in theintervention and treatment process, whatever the long-term goals are. In specialized treatment,intermediate goals might include quitting one substance, decreasing frequency of use, attendingthe next meeting, or doing the next homework assignment. Immediate successes are important tokeep the client motivated.Setting goals for clients is particularly useful in centers that specialize in substance abusetreatment. Performing brief interventions in this setting requires the ability to simplify andreduce a client's treatment plan to smaller, measurable outcomes, often expressed as "objectives"in the Joint Commission on the Accreditation of Healthcare Organizations' (JCAHO) language of treatment planning. The clinician must be aware of the many everyday circumstances in whichclients with substance abuse disorders face ambivalence during the course of treatment.The key to a successful brief intervention is to extract a single, measurable behavioral changefrom the broad process of recovery that will allow the client to experience a small, incrementalsuccess. Clients who succeed at making small changes generally return for more successes.The clinician should temporarily set aside the final goal (e.g., accepting responsibility for one'sown recovery) to focus on a single behavioral objective. Once this objective is established, a brief intervention can be used to reach it. Objectives vary according to the client's stage of recovery and readiness to change, but brief interventions can be useful at any stage of recovery.Figure 2-2 presents several objectives that might be addressed with a brief intervention.The following are suggested goals for brief interventions according to the client's level of consumption.Abstainer Even though abstainers do not require intervention, they can be educated about substance usewith the aim of preventing a substance abuse disorder. Such prevention education programs are particularly important for youth.Light or Moderate User The goal of a brief intervention with someone who is a light or moderate user is to educate her about guidelines for low-risk use and potential problems of increased use. Even light or moderateuse of some substances can result in health problems or, in the case of illicit substances, legal problems. These users may also engage in binge drinking (i.e., five or more drinks in a singleoccasion). Clients who drink should be encouraged to stay within empirically establishedguidelines for low-risk drinking (no more than 14 drinks per week or 4 per occasion for men andno more than 7 drinks per week or 3 per occasion for women [American Society of AddictionMedicine (ASAM), 1994]).Brief interventions can enhance users' insight into existing or possible consequences or drawattention to the dangers associated with the establishment of an abusive pattern of substance use.

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